http://dx.doi.org/10.

17159/2519-0105/2017/v72no6a5
case report <
271

Managing sodium hypochlorite

accidents: the reality of toxicity
SADJ July 2017, Vol 72 no 6 p271 - pxxx

E Patel1, M Gangadin2

Abstract
Sodium hypochlorite (NaOCl) is the most commonly ACRONYMs
used endodontic irrigant due to its effective antimicrobial NaOCl: sodium hypochlorite
function and ability to dissolve organic matter. However, NSAID: non-steroidal anti inflammatory drug
when NaOCl escapes from the root canal system,
the cytotoxic effects are severe, regardless of the An increase in NaOCl concentration leads to an increase
concentration used. in cytotoxicity.11
A case of undiagnosed external root resorption that lead We present a protocol for the management of a NaOCl
to the extrusion of a 1% NaOCl solution into the periapical accident with an illustrative case.
soft tissues is presented. This report considers guidelines
and highlights the obligation of clinical practices to CASE REPORT
develop protocols for, and to maintain, the ability to
A 70 year old female patient with a complex medical
manage and treat accidents involving NaOCl.
history presented to the Wits Oral Health Centre with a
Keywords: Sodium hypochlorite accident, irrigation main complaint of ‘feeling an abscess in her front tooth’.
Highlights from her medical history included hypertension,
toxicity, tissue necrosis.
hyperlipidaemia, a peptic ulcer, an earlier angiogram and
INTRODUCTION cardiac coronary bypass, a cataract in right eye, and a
hypersensitivity to penicillin. She explained that for one
The earliest reported use of sodium hypochlorite (NaOCl) week she had noticed pus draining from the gum area
was limited to stain removal in clothing. The first evidence below her lower front tooth. She had no associated pain.
of its use in endodontics was published by Coolidge Her dental history included multiple prior extractions
and Crane in 1919 and 1920, respectively, long after it due to caries and she wore a single maxillary complete
had been recognized in 1843 as an antimicrobial agent. denture constructed in 2001.
NaOCl continues today to serve as an endodontic irrigant,
its popularity stemming from its role in the dissolution of Extra-oral examination revealed bilateral masseteric
organic matter.1,2 The hypochlorite ion irreversibly oxidizes tenderness. Intra-orally, only the six lower anterior teeth
enzymes, thereby terminating the metabolic activities of were present, all with generalized attrition. The right
tissues or organisms it contacts. The reaction of NaOCl lower lateral incisor was tender to percussion and non-
with lipids and amino acids in pulpal tissue leads to responsive to thermal tests. A buccal vestibular draining
liquefactive necrosis within minutes.3-7 sinus with inflammation of the adjacent labial mucosa
was found. Radiographically, widening of the lamina dura
There is no consensus as to the most effective in the apical third of the tooth was observed. Root canal
concentration of NaOCl when used as endodontic treatment was initiated for the lower right lateral incisor.
irrigant, but an empirical concentration range of 0.5% to The endodontic protocol of the clinic was followed and
≥5.25% is generally accepted.8-10 included rubber dam isolation, access cavity preparation
using the Endo Access Kit® (Dentsply, South Africa), and
1. Ebrahim Patel: BDS, MScDent. Lecturer, Division of Operative extirpation using k-files. Irrigation was performed using a
Dentistry and Endodontics, Department of Oral Rehabilitation, School 1% NaOCl solution via a side-ported needle and syringe
of Oral Health Science, Faculty of Health Sciences, University of the
Witwatersrand.
delivery. NaOCl was introduced into the coronal third of
2. Megna Gangadin: BDT, BDS, PG Dip Dent. Lecturer, Division the root canal and thereafter advanced to the middle
of Operative Dentistry and Endodontics, Department of Oral third. The patient reported severe burning with pain
Rehabilitation, School of Oral Health Science, Faculty of Health radiating down the neck following syringe withdrawal. As
Sciences, University of the Witwatersrand.
per protocol (Table 1) aspiration of the residual NaOCl
Corresponding author was immediately attempted. Local anaesthetic (Xylotox
Ebrahim Patel: E80-A) and saline were introduced to dilute the effects of
Department of Oral Rehabilitation, School of Oral Health Sciences, the NaOCl as well as to assist with analgesia. A calcium
Faculty of Health Sciences, University of the Witwatersrand, South
Africa, 7 York Road, Parktown, 2193. Cell: 082 495 5164. hydroxide dressing (AH Temp®; Dentsply, South Africa)
E-mail: [email protected] was inserted into the root canal after which a resin-
272 > case report

Table 1: Clinical Guidelines following NaOCl accident of the Wits Oral Health Centre (Adapted from Bosch-Aranda et al. 2012)
Period Action
Immediately 1. Aspiration of all possible NaOCl from site of entry
following 2. Local anaesthetic to assist analgesia
extrusion of/ 3. Saline to assist dilution of the irrigant
exposure to 4. Tooth temporized with a calcium hydroxide intra-canal medicament and resin-modified glass ionomer restoration
NaOCl 5. Prescribe analgesics and anti-inflammatories (First choice is NSAIDS such as Ibuprofen. If contraindicated then
a steroid such as methylprednisolone and an opioid such as tramadol, where indicated)
6. Case evaluation by a maxillofacial surgical consultant
7. Patient must be advised to apply cold packs to facial region (to prevent/limit further swelling)
24 hours 1. Assess clinical sequelae of accident and severity
post-accident 2. Antibiotics – prescribed on basis of anticipated necrosis
3. Chlorhexidine mouthwash
4. Patient must be advised to apply hot packs and rinse frequently with warm oral rinses (to stimulate local circulation)
7 days 1. Reassess clinical sequelae and severity
post-accident 2. Maxillofacial consultation
14 days 1. Reassess healing to date
post-accident 2. Continue with endodontic treatment (if healing satisfactory)
3. Alternate irrigants must be used (eg. EDTA, Chlorhexidine)

modified glass ionomer (Vitremer ®; 3M, South Africa) was DISCUSSION

placed as a temporary restoration. An analgesic (Tramadol, Sodium hypochlorite is the most commonly used
50mg, twice daily) and a steroid (Methlyprednisolone,
endodontic irrigant worldwide and continues to be
20mg, at night for five days) were prescribed. Antibiotics
favoured as it remains the only material capable of
were not prescribed at this stage as major necrosis was
dissolving organic tissue within the root canal system.10,12-17
not envisaged.
Although NaOCl is regarded as safe for endodontic use,
The patient was contacted telephonically in the first 24 the cytotoxic results of mishaps and/or accidents must
hours and was clinically reassessed at 48 hours post- be highlighted. It is essential that clinicians are trained,
accident. Several signs and symptoms were observed and remain skilled and equipped, to deal immediately and
including: pain, dysphagia, and a midline swelling in the effectively with any repercussions of a NaOCl accident.
neck extending down to the level of the hyoid bone which
The concentration of NaOCl required to efficiently
was tender to palpation (Figure 2 A,B). Intra-orally, buccal
disinfect the root canal system has long been a topic
gingival necrosis was noted about 1cm in diameter and
with a mildly erythematous border (Figure 3 A). Superficial of debate. The Wits Oral Health Centre (Johannesburg,
sublingual necrosis, approximately 2cms in diameter, was South Africa) employs a 1% NaOCl solution in its
also observed in the mucosa of the floor of the mouth undergraduate endodontic clinic. The rational for this is
(Figure 3B). At this stage, an antibiotic (Clindamycin, 300mg, that: (a) comparatively lower concentrations are safer
twice daily for five days), coupled with a chlorhexidine
mouthwash was prescribed. Clindamycin was chosen for
this patient due to her penicillin hypersensitivity; and the
twice daily regimen provides for better patient compliance
than a 6-hourly dose.

The patient was recalled again eight days after the

incident. She reported that whilst the pain had dissipated,
her dysphagia had still persisted. Extra-orally, resolution
of the neck swelling could be appreciated (Figure 2C,
D). Intraorally, the buccal gingiva healed uneventfully
(Figure 4A). The previously superficial sublingual necrosis
advanced to an ulcer with the concomitant development Figure 1: Preoperative panoramic radiograph exhibiting the six remaining
of a second ulcer in the contralateral side of the floor of mandibular teeth
the mouth (Figure 4B). At this stage class III mobility was
recorded for the lower right lateral incisor and canine.
As outlined by the protocol in Table 1, these findings
prompted consultation with a maxillofacial surgeon who
further guided the management of this case, and the
patient was assessed bi-weekly.

At eight weeks post-accident, the patient was re-examined

and the panoramic radiograph displayed a radiolucent
lesion, extending 20mm apical to the lower right lateral
incisor, approximately 15mm in width (Figure 5). This
finding, coupled with the persistent class III mobility on
the lower right lateral incisor and canine led to both teeth
being extracted. Four months later complete healing had
taken place. The treatment plan was resumed and a Figure 2: Comparative decrease in the neck swelling from 48 hours post-
mandibular partial denture was constructed. accident (A, B) to that of eight days after (C, D).
www.sada.co.za / SADJ Vol 72 No. 6
case report <
273

for use by novice clinicians, and (b) by increasing the The commonly reported clinical sequelae following a
volume of irrigant used, with regular exchange, the NaOCl accident include: pain, ecchymosis, swelling,
antimicrobial efficacy of lower concentrations of NaOCl chemical burns and necrosis, ulceration, neurologic
solution is sustained.18 This case reinforces the fact that damage (paraesthesia and anaesthesia) and at times
even at reduced concentrations, NaOCl retains potent respiratory compromise. Multiple factors influence the
cytotoxicity that demands extreme caution during use. progression of these clinical sequelae (Figure 6). The
volume of NaOCl that enters the tissues and the clinician’s
NaOCl extrusion beyond the apical foramen is an reaction time to recognize and initiate treatment protocols
infrequent occurrence and is rarely reported. However, have perhaps the most critical influence.19-25
iatrogenic damage and/or pathologic processes such as
root canal perforation, poor length control during canal Pain is a hallmark of tissue injury and was reported in
preparation, and external root resorption favour this this case within seconds of the accident. Swelling of
complication when their presence is undiagnosed.27 In the surrounding mucosa, subcutaneous tissue and skin
this case, external root resorption in the apical third of occurred a few hours later. This inflammatory response
the root canal, undetectable with routine two dimensional originates from the reaction of hypochlorite ions with
apical radiographs, permitted the exit of the NaOCl into proteins and lipids resulting in soluble soap complexes that
the periapical tissue. The incident highlights the limitations facilitate the permeation of the ion deeper into the tissue.
of two-dimensional radiographs in endodontic diagnosis This process complicates efforts to neutralize or dilute
and preoperative assessment. the NaOCl.3,26 Furthermore, tissue necrosis of the fascial
spaces is not uncommon in cases of NaOCl extrusion and
is a direct result of a chemical burn in the tissue.

In a review of clinical characteristics following NaOCl

accidents, Zhu et al. (2013) observed reports of a higher
occurrence of ecchymosis in the periorbital and angle of
mouth regions.27 According to their findings, the mode
of spread was associated with anastomoses around the
facial vein that permitted the rapid spread of the NaOCl
Figure 3: .A: Irregular buccal gingival necrosis (lower right lateral incisor) ap- solution. Minimal bruising/ecchymosis was observed in this
proximately 1cm in diameter. B: Sublingual superficial necrosis posterior to the case due to the anatomy of the sublingual fascial space.
lower right lateral incisor, with an erythematous border.

Anatomically, the sublingual space is delineated by the

mucosa of the floor of the mouth superiorly, the mylohyoid
muscle inferiorly and the lingual surface of the mandible
laterally. Its contents include the submandibular (Whartons)
duct, lingual nerve, sublingual gland and the sublingual artery
and vein.28 The space is divided in the midline only by loose
connective tissue which explains the spread of the NaOCl to
the contralateral side (from the sublingual region of tooth 42
Figure 4: A: Buccal gingival healing observed eight days post-accident.
to that of tooth 32). Furthermore, the mucosa of the floor of
B: Advancement of the sublingual necrosis to complete ulceration with the
addition of a secondary ulcer in the sublingual region adjacent to the lower the mouth is classified histologically as lining mucosa - a thin,
left lateral incisor. non-keratinized layer of epithelium with an underlying lamina
propria.29 The friable nature of this tissue and its relative
inability to act as an effective barrier against NaOCl further
explains the chemical burns and subsequent ulcers that were
encountered in both the right and left sublingual regions.

Antibiotics, analgesics and anti-inflammatory drugs are

often prescribed following a NaOCl accident. The choice
of drugs used for this case was selected based on the
patient’s medical conditions. Although a non-steroidal
anti-inflammatory (NSAID) is the first drug of choice to limit
immediate swelling, a steroid (methylprednisolone) was
prescribed in this case due to the patient’s intolerance to
NSAIDS. In addition, the gastrointestinal side effects of the
Figure 5: Panoramic radiograph following extraction of the lower right lateral steroid were neutralized by the patient’s chronic medication
incisor and canine. The red marking delineates the extent of the radiolucent - Omeprazole (20mg). Even though antibiotic prescription
area observed beyond the extracted teeth. is based on the merit of each NaOCl accident case, and
on the expectancy of moderate to severe necrosis of the
affected tissue, it is still largely empirical.

In this case, the decision to delay prescribing an antibiotic

was due to the clinician envisaging minimal to no tissue
necrosis. However, following observation of the resultant
buccal and lingual necrosis at the 48 hour recall visit
this decision was revised to prevent the development of
secondary infection. Clindamycin is the second drug of
choice where patients are allergic to penicillin and was
Figure 6: Factors contributing to the clinical severity of NaOCl accidents.30-35
274 > case report www.sada.co.za / SADJ Vol 72 No. 6

prescribed as the preferred twice-daily dose to improve 12. Dutner J, Mines P, Anderson A. Irrigation trends among
compliance over the 6-hourly dose. American Association of Endodontists Members: A web-
based survey. Journal of Endodontics 2012; 38: 37–40.
13. Unal GC, Kaya BU, Tac AG, Kececi AD. Survey of attitudes,
Exigency is an important factor for the successful
materials and methods preferred in root canal therapy by
management of NaOCl accidents. The time taken by general dental practice in Turkey: Part 1. European Journal of
clinicians to recognize and diagnose the incident, and the Dentistry 2012; 6: 376–84.
immediate implementation of a NaOCl incident protocol 14. Udoye CI, Sede MA, Jafarzadeh H, Abbott PV. A survey of
have an influence on the severity and outcome of the endodontic practices among dentists in Nigeria. The Journal
clinical sequelae in the days that follow. The Wits Oral of Contemporary Dental Practice 2013; 14: 293.
15. Willershausen I, Wolf TG, Schmidtmann I, Berger C,
Health Centre follows a specific set of guidelines developed Ehlers V, Willershausen B, Briseño B. Survey of root canal
for the management of NaOCl accidents (Table 1). These irrigating solutions used in dental practices within Germany.
guidelines emphasise the uniqueness of each case and International Endodontic Journal 2015; 48: 654–60.
that intervention or treatment decisions are made on a 16. Tosic G, Miladinovic M, Kovacevic M, Stojanovic M. Choice
case-to-case basis that relies on additional empirical input. of root canal irrigants by Serbian dental practitioners.
The follow-up period varies based on the specific signs Vojnosanitetski pregled 2016; 73: 47–52.
17. Cobankara FK, Ozkan HB, Terlemez A. Comparison of
and symptoms that present in each patient during the organic tissue dissolution capacities of sodium hypochlorite
course of the incident. In this case, the patient was recalled and chlorine dioxide. Journal of Endodontics 2010; 36: 272–4.
(in addition to the guidelines) at four weeks, six weeks and 18. Siqueira JF, Rôças IN, Favieri A, Lima KC. Chemo-mechanical
eight weeks post-accident. This was due to the persistent reduction of the bacterial population in the root canal after
mobility on teeth 42 and 43, which were extracted at week instrumentation and irrigation with 1%, 2.5%, and 5.25%
sodium hypochlorite. Journal of Endodontics 2000; 26: 331–4.
eight. Healing of the extraction sites was uneventful. 19. Bosch-Aranda M, Canalda-Sahli C, Figueiredo R, Gay-
Escoda C. Complications following an accidental sodium
CONCLUSION hypochlorite extrusion: A report of two cases. Journal of
NaOCl remains the irrigant of choice for endodontic Clinical and Experimental Dentistry 2012; e194–e198.
treatment due to its ability to dissolve organic tissue and 20. Aguiar BA, Gomes FA, Ferreira CM, Sousa BCD, Costa FWG.
Hypochlorite-induced severe cellulitis during endodontic
resultant antimicrobial activity. However, the cytotoxicity treatment: case report. RSBO (Online) 2014; 11(2): 199-203.
of the medication requires caution during clinical 21. Gomes FA, Costa FW, Sousa BC, Aguiar BA, Ferreira
procedures. Not only is it imperative that undergraduate CM. Hypochlorite-induced severe cellulitis during endodontic
and postgraduate endodontic curriculums highlight the treatment: case report. Revista Sul-Brasileira de Odontologia
possibility of NaOCl accidents, the avoidance and the 2014; 11: 199–203.
management thereof, but that clinicians remain skilled 22. Goswami M, Chhabra N, Kumar G, Verma M, Chhabra
A. Sodium hypochlorite dental accidents. Paediatrics and
and equipped to deal appropriately and timeously with International Child Health 2014; 34: 66–9.
the repercussions of an accident. 23. Matthews J, Merrill RL. Sodium hypochlorite–related injury
with chronic pain sequelae. The Journal of the American
Conflict of Interest: None declared
Dental Association 2014; 145: 553–5.
24. Al-Sebaei M, Halabi O, El-Hakim I. Sodium hypochlorite
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